Nokea
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water-seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Continuous bubbling in the water seal chamber
- C. Absence of bubbling in the water seal chamber
- D. No drainage in the collection chamber
Correct Answer: A
Rationale: Fluctuation (tidaling) in the water-seal chamber during inspiration and expiration indicates the chest tube is functioning properly.
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The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications?
- A. Furosemide
- B. Carvedilol
- C. Spironolactone
- D. Lisinopril
Correct Answer: B
Rationale: The correct answer is B: Carvedilol. Carvedilol is a beta-blocker, which can exacerbate asthma symptoms in clients with a history of asthma due to its potential bronchoconstrictive effects. Furosemide (A), Spironolactone (C), and Lisinopril (D) are commonly used in heart failure management and do not pose a significant risk for clients with asthma. It is crucial to avoid medications that can worsen respiratory function in clients with a history of asthma to prevent complications.
A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
- A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
- B. pH 7.40, HCO3- 24 mEq/L, PaCO2 38 mm Hg
- C. pH 7.45, HCO3- 28 mEq/L, PaCO2 40 mm Hg
- D. pH 7.50, HCO3- 30 mEq/L, PaCO2 45 mm Hg
Correct Answer: A
Rationale: The correct answer is A (pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg). In chronic kidney disease, the kidneys are unable to excrete acid effectively, leading to metabolic acidosis. The pH is low (acidotic) due to the accumulation of acids. The bicarbonate (HCO3-) is low (19 mEq/L) as the kidneys are unable to reabsorb and regenerate bicarbonate effectively. The PaCO2 is low (30 mm Hg) as the respiratory system compensates by increasing the respiratory rate to blow off carbon dioxide in an attempt to normalize the pH. Choices B, C, and D have pH values within normal range and do not reflect the expected acidosis in chronic kidney disease.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
- A. The client who has a wound infection and is on antibiotics.
- B. The client who has gastroenteritis and is febrile.
- C. The client who is receiving IV fluids and is in pain.
- D. The client who is on a clear liquid diet and has hypokalemia.
Correct Answer: B
Rationale: The correct answer is B. The client with gastroenteritis and fever is at risk for fluid volume deficit due to increased fluid loss from vomiting and diarrhea. Fever also increases fluid loss through perspiration. The other choices do not directly indicate increased fluid loss. A: Antibiotics for wound infection may not directly lead to fluid volume deficit. C: IV fluids would help maintain hydration status, so this client is not at risk for deficit. D: Hypokalemia may be related to electrolyte imbalance, but not necessarily fluid volume deficit.
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
- A. Discontinue the existing IV line
- B. Apply warm compresses
- C. Elevate the extremity
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct action is to discontinue the existing IV line first. This is crucial because the client is exhibiting signs of infiltration, which can lead to tissue damage and complications. By removing the IV line, further damage can be prevented. Applying warm compresses or elevating the extremity may not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider is important but should not be the first step in this situation.
A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching?
- A. I will eat food that are served at room temperature.
- B. I will eat food that is very hot.
- C. I will drink large amounts of fluids with meals.
- D. I will eat a large meal right before chemotherapy.
Correct Answer: A
Rationale: Correct Answer: A: "I will eat food that is served at room temperature."
Rationale: Eating foods at room temperature can help decrease nausea because hot foods may worsen nausea, while cold foods could cause stomach discomfort. Room temperature foods are generally easier on the stomach and may be better tolerated during chemotherapy and radiation. This choice demonstrates an understanding of how food temperature can impact nausea.
Summary of other choices:
B: Eating very hot food can actually worsen nausea.
C: Drinking large amounts of fluids with meals can dilute stomach acid and enzymes, potentially worsening nausea.
D: Eating a large meal right before chemotherapy can lead to increased nausea and discomfort.